Healthcare Provider Details

I. General information

NPI: 1093334435
Provider Name (Legal Business Name): HALEN CLINTON HULSEBUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 02/08/2023
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 W ROWEL RD
PHOENIX AZ
85083-1633
US

IV. Provider business mailing address

4220 W ROWEL RD
PHOENIX AZ
85083-1633
US

V. Phone/Fax

Practice location:
  • Phone: 623-521-1232
  • Fax:
Mailing address:
  • Phone: 623-521-1232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8234
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: